Provider Demographics
NPI:1609069087
Name:CLARK, KIM J (LMP)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2901
Mailing Address - Country:US
Mailing Address - Phone:360-425-6620
Mailing Address - Fax:360-425-1277
Practice Address - Street 1:1424 16TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2901
Practice Address - Country:US
Practice Address - Phone:360-425-6620
Practice Address - Fax:360-425-1277
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018876225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist